Antitrust 101: How to Build Medical Monopolies by Discrediting U.S. Physicians

Recently, there have been a rash of initiatives by unaccountable non-profit physician credentialing organizations (Federation of State Medical Boards, the American Boards of  Internal Medicine, Family Medicine and Pediatrics), and the American Medical Association to come to the public's rescue by de-credentialing U.S. physicians they accuse of spreading misinformation during the COVID-19 pandemic.

Physicians have seen this medical monopoly-building playbook before.

The video below reviews the antitrust, monopoly-making activities of the American Board of Internal Medicine (ABIM). The discrediting of certain U.S. physicians as "cheaters" and disseminators of "misinformation" serve as a smokescreen to their monopoly-building activities. As physicians worked tirelessly to care for patients during the COVID-19 pandemic, the ABIM used U.S. physicians' testing fees to redistribute physician testing fees for their "social justice" initiatives, most significant of which was lobbing Congress so their separate Maintenance of Certification (MOC) continuous testing produt would be a never-ending source of revenue and data metrics used by the Medical Industrial Complex. Sadly, this mandate on younger, more vulnerable ABMS-board certified US physicians has harmed hundreds of physicians and tens of thousands of patients as physicians burn out and leave the profession.

For all patients who wonder why health care prices are so high and access to a board-certified physician has become so difficult, look no further than the organizations above. 

Is ABIM Ending Its "Knowledge Check-In" MOC® Pathway?

The following (redacted) email was received from Morgan Allen, Customer Relationship Advocate at the American Board of Internal Medicine (ABIM), in response to an ABIM diplomate that was unable register online for their every-two year Knowledge Check-In "continuous" Maintenance of Certification (MOC®) product.

According to this email, it seems the ABIM has decided to end its Knowledge Check-In recertification pathway and only permit its every-10-year high-stakes recertification examination for physicians to remain ABIM Board Certified.

At the time of this writing, I could find no public notification of this policy change on ABIM's website. Once again, working physicians are irresponsibly left uncertain of the latest requirements to remain ABIM Board Certified in good standing.

ABIM has a long history of changing the rules for the names and requirements for physician board recertification/maintenance of certification/continuous certification. But despite the many name and rule changes of this racket, each rebranding becomes more expensive and serves to perpetuate the discrimination against younger physicians and physicians of color from senior "grandfathered" physicians who are not required to purchase these products to retain their ABIM Board Certified status. The Knowledge Check-In recertification pathway was no different from its predecessors in this respect. But the Knowledge Check-In pathway also suffered from a plethora of technical, security, and (undisclosed) privacy issues for physicians. (See my earlier video that critically reviewed this recertification pathway and the people who created it.)

One thing is a constant, however. Ever since the ABIM changed Board certification from a lifetime to time-limited physician marketing accolade, this unproven repeated testing of working physicians remains a career-long psychological and economic stressor that distracts from what matters most: patient care.

-Wes

ABIM Stumbles in Appellate Court Arguments

The oral arguments in the appeal of the dismissal at the District Court level of the Kenney et al vs American Board of Internal Medicine (ABIM) class action antitrust, RICO, and unjust enrichment case were heard before the 3rd Circuit Court of Appeals today and are available via audio file here. The following interchange starting at 32:58 in the audio file was interesting (I have added a few personal comments/thoughts in italics):

Judge: "Could I just ask the follow-up there about forcing? How do we conclude that internists aren't forced to buy MOC at this stage in the litigation in light of the allegations that internists can't successfully practice without certification? Isn't the feasibility of practicing without certification ultimately a question of fact?"

ABIM Attorney: "I think you can first look to, um, look to the facts in this case. For instance, Dr. Manolo who, who never, who did purchase initial certification and never purchased Maintenance of Certification. I think that certainly shows that his purchase of initial certification was not contingent on the later purchase of Maintenance of Certification. (Comment: It also shows there are two products). So I think that is one way you can look at it. I think you can also look at it in the way that the Second Circuit indicated in the Smugglers Notch Homeowner's case which is a case where, which looked at, when you're entering in to the transaction and you know that, in fact, you're that going to be required, there are certain components, parts, of that entire transaction, and you know that up front, and you voluntarily nonetheless enter into that contract, that there is no forcing." 

Judge: "But counselor, what I'm talking about is it might not be so voluntary - they want to make a living, are they forced to buy your product? You seem to say no they're not forced to, but is that essentially an issue of fact more appropriate for summary judgement?"

ABIM Attorney: "Um, I would suggest not because I think when courts look to forcing they look at what is the situation at the time of the initial purchase? At the time of the initial purchase here ABIM had a program for certification and aspects of that program were initially passing the initial board certification exam and that that certification would expire after a set period of time - ten years - without unless diplomate passed subsequent examinations. And so when they, up front, bought that product they knew there would be a continuing obligation as part of the certification program, that they would have to demonstrate, in fact, that they possess the requisite knowledge to hold themselves out and say "Yes, I am ABIM, or board certified." So there is no forcing because there is the knowledge up front at the time of purchase of what certification entails, um, and that was the periodic demonstration of knowledge."

Judge: "But I suppose that the most basic form of your argument is, they don't have to go through ABIM to practice." 

ABIM Attorney: "Yes, your Honor. If you look at the Amended Complaint, the Amended Complaint is quite clear that board certification is not required to practice medicine in the United States. That is simply a function of state boards of medicine that license doctors. Um, you only need a license in your state, um, to practice medicine. Board certification is not required. Board certification is more like the "Stamp of Approval" that you can hold yourself out to have special qualifications. (As I have said all along, board certification is actually little more than a marketing accolade.) Some patients and employers look to that, others do not, but it is not a requirement to practice medicine in any state in the United States which is a fact that is pled in the Amended Complaint."

Judge: "But this does go to your market power, I mean, yeah, it's true, you don't need the ABIM certification. But is it really feasible not to have it, in reality? And I think, the allegations, don't they say, a lot of places won't let you practice, your malpractice rates are going to go higher, reimbursement's going to be an issue. So is it really feasible to practice without certification and is that something that should be a subject of discovery as opposed to, you know, at this juncture with a motion to dismiss to resolve?"

ABIM Attorney: "Well. well many, I would submit many internists do, in fact, practice medicine, um, without ABIM certification and there are many things that might affect how much you are paid, what your admitting privileges are - things like where you attended medical school and many other factors. (Comment: And if you believe this, I have some ocean-front property to sell you in Arizona). But it really comes back to, you know, what is at issue in this case and whether, in fact, there is a tying claim and whether or not there is, um, one product or two products and that really goes back to the Supreme Court test in Jefferson Parish about the character of demand and whether there is demand for the tied product in absence of the typing product.  And here, the Appellants want to hold themselves out as being "board certified." There is no separate demand for the tied product in the absence of the tying product. And that is something I think is, is something that, you know, the Court in Jefferson Parish makes clear. Justice O'Connor when she expands on the words in that saying that for products to be treated as distinct, the tied product must, at a minimum, be one that consumers might wish to purchase separately without also purchasing the tying product. And here's.. there's simply... there are no allegations of fact sufficient to move this case along to make a plausible case that there are, in fact, two products here because there is no consumers, there are no allegations showing there is demand to purchase the tied product without also tying the tying product." (Comment: OMG, Seriously?)

Judge: "Alright, thank you counsel."

The judges asked the right questions. Now we have to wait to see if this case is sent back to the District Court for discovery.

I will have additional comments about other aspects of these oral arguments in the days ahead.

-Wes

P.S.: MedpageToday covered the story as well here.

PPS: If you'd like to help the plaintiff's along their lengthy legal quest to improve the lot for all US physicians regarding MOC, please contribute to the GoFundMe page sponsored by Practicing Physicians of America.

Physician Plaintiffs File Reply Brief Against ABIM

The four Internal Medicine physician Plaintiffs-Appellants filed their latest Reply Brief in the class action lawsuit against the American Board of internal Medicine (ABIM) today. That reply brief summarized the alleged tying arrangement of ABIM board certification to "Maintenance of Certification (MOC)":

"ABIM’s monopoly power over certifications is undisputed. Certifications are an economic necessity for a successful medical practice. From 1936 to today ABIM certifications have assessed one thing: postgraduate medical education. 

Realizing that only so much in certification fees can be extracted from new residency graduates, MOC allows ABIM not only to charge internists a one-time certification fee at the outset of their practice, but to force internists to purchase MOC by revoking their “initial” certifications if they do not, requiring them to pay inflated MOC fees throughout their entire decades-long careers. The two products are separate because, in ABIM’s own words, MOC “means something different” from certifications and “speaks to the question of whether or not an internist is staying current.” (¶ 53). MOC’s true purpose, however, is to create a lucrative revenue stream for ABIM, resulting in hundreds of millions of dollars in new fees. (¶ 65). 

There are other products—not sold by ABIM—that help internists stay current, including continuing medical education products (“CME”). (¶ 54 (“MOC serves substantially the same function as CME”)).1 

MOC is ABIM’s fourth attempt to sell a product distinct from certifications to help keep internists current. Thousands of internists bought three previous voluntary MOC products separately from their certifications as part of ABIM’s Continuous Professional Development Program (“CPD”). (¶ 25). “Grandfathers” today also purchase MOC separately from their certifications. (¶ 35). Purchases by internists of MOC, CME, and other non-ABIM CPD products to stay current, demonstrate distinct demand for those products separate from the demand for certifications. ABIM’s earlier versions of MOC failed to generate the hoped-for revenue because ABIM did not revoke certifications of internists who did not buy them. That ABIM’s voluntary products were unsuccessful reflected internists’ preferences to buy products from others to stay current. (¶ 55). ABIM ensured, however, that MOC succeeded by tying it to “initial” certifications and making it mandatory. (emphasis mine) Plaintiffs’ claims do not threaten ABIM “standards” any more than ABIM’s earlier voluntary MOC products did. Plaintiffs ask only that ABIM’s illegal tie be severed and that MOC once again be voluntary."

In addition, the filed brief explains the basis of the RICO claims made by the physician Plaintiff-Appellants against the ABIM: 

"After ABIM was unable to generate hoped-for fees from its first three voluntary MOC products sold as part of its CPD Program, it realized it must force internists to buy MOC. ABIM did so by revoking the certifications of internists who did not buy MOC. In furtherance of its scheme, ABIM waged a campaign of fraudulent misrepresentations to deceive the public, including but not limited to hospitals and related entities, insurance companies, medical corporations and other employers, and the media, that MOC, among other things, benefits physicians, patients and the public and improves patient outcomes. As a result, ABIM has collected hundreds of millions of dollars in MOC fees under false pretenses."

Finally, in regard to the unjust enrichment claim dismissed by the earlier District Court judge:

"The district court’s sole rationale for dismissing Plaintiffs’ unjust enrichment claims is its conclusion that ABIM “did not ‘force’ Plaintiffs to purchase MOC.” A-41. ABIM similarly repeats its argument that internists “chose” to “pursue and maintain their certifications.” ABIM Br. 54. Plaintiffs have already debunked this argument, and clearly allege “forcing” notwithstanding the erroneous conclusions and arguments of the district court and ABIM. 

ABIM points out that certifications are not required for licensure. But it does not deny certifications are required for admitting privileges, insurance, and other requirements of a successful medical practice, and accordingly are an economic necessity. Finally, the district court opinion in In re Avandia Mtkg., No. 2007-MDL-1871, 2013 U.S. Dist. LEXIS 152726 (E.D. Pa. Oct. 22, 2013), does not support ABIM, as the unjust enrichment claim there failed for several reasons not pertinent here, most importantly because, unlike MOC, the purchases were voluntary. See ABIM Br. 55-56."

With this filing, it is clear that the class action lawsuit filed by working physicians against the ABIM is far from over. Read the whole Reply Brief here. 

-Wes

To support the physician plaintiffs in this ongoing lawsuit, consider contributing to their GoFundMe page.

Just In Time for Christmas: The MOC Legal Juggernaut Intensifies

With the recent back-to-back announcements that the class action antitrust and racketeering lawsuit against the American Board of Internal Medicine (ABIM) and the antitrust lawsuit against the American Board of Radiology were dismissed (e.g., the ABIM announcement and ABR announcement), doctors everywhere - both young and old - seemed resigned to the fact that they will have to be subjects to lifelong extortion of private American Board of Medical Specialties member boards and their affiliates if they wanted to practice medicine in the United States.

But fear not, dear colleagues. I bring you tidings of great joy. The first great Supplemental Opposition to the Motion to Dismiss the lawsuit against the American Board of Psychiatry and Neurology (ABPN) was filed yesterday that promises to renew the call for justice on the basis of proper legal procedural grounds:

Defendant American Board of Psychiatry and Neurology (“ABPN”) illegally ties its initial certification product, which it sells to new doctors to demonstrate completion of their medical education and assess the quality of their residency program, and its MOC product, which it requires some older doctors, but not all, to purchase throughout their careers to demonstrate lifetime learning or forfeit their initial certification. ABPN brings to the court’s attention Kenney v. American Board of Internal Medicine, No. 18-5260, 2019 U.S. Dist. LEXIS 164725 (E.D. Pa.Sept. 26, 2019) (“Kenney”), and Siva v. American Board of Radiology, No. 19 C 1407, 2019 U.S. Dist. LEXIS 200645 (N.D. Ill. Nov. 19, 2019) (“Siva”). Kenney came first, followed by Siva which “agree[d] with the reasoning in Kenney.” Id. at *11.¹

Nothing in those opinions changes ABPN’s unlawful conduct. A critical reading of the opinions and application of the universally accepted rule that well-pleaded factual allegations and all reasonable inferences therefrom must be taken as true compels the conclusion that Kenney and Siva were, respectfully, wrongly decided.

¹  The tying claims in Kenney were dismissed with prejudice without plaintiffs being allowed to amend, the court finding as a matter of law that separate products could never be alleged. Plaintiffs are appealing that ruling. The claims in Siva were dismissed without prejudice and plaintiff is filing an amended complaint on January 10, 2020.

The supplemental opposition to the ABPN motion to dismiss then outlines multiple legal reasons why the plaintiffs believe the decisions were wrongly decided. In essence, the attorneys are arguing that the facts in this case were not even allowed to be considered past the judges' chambers.

We can anticipate that the multitude of moneyed interests behind Maintenance of Certification will stop at nothing to assure this unlawful program continues unchecked.

Still, a bit of hope and cheer is always welcome for working physicians this time of year.

Merry Christmas!

-Wes

P.S.: On a separate legal note:

Remember the Puerto Rican physician, Jaime Salas Rushford, MD, whom the ABIM revoked his board certification and dragged him through the court system since 2012 with a dismissed time-barred cheating claim while the President and CEO of the ABIM simultaneously failed to disclose her conflicts of interest with Kaiser and Premier Inc? Yesterday, the judge issued the following order to expedite the counterclaim suit filed against ABIM by Salas Rushford:

The American Board of Internal Medicine may file its motion for judgment on the pleadings no later than December 18, 2019. Dr. Salas-Rushford will respond no later than January 2, 2020. The Board may reply no later than January 9, 2020. The case schedule will be discussed at the scheduling conference to be held on January 31, 2020. Signed by Judge Francisco A. Besosa on 12/11/2019. (brc) (Entered: 12/11/2019)

It seems that case will soon be coming to a head, too.

Readers wishing to support the brave physician plaintiffs involved in these lawsuits trying to end the unlawful Maintenance of Certification program are encouraged to contribute to their GoFundMe campaign.

Plaintiffs to Appeal ABIM Class-Action Lawsuit in Full

With the time to amend the earlier class action antitrust and racketeering lawsuit against the American Board of Internal Medicine (ABIM) past, this statement was issued by C. Phillip Curley, the Plaintiffs' lead attorney:

“Plaintiffs plan to appeal in full the dismissal of their case. While we respect the district court, we believe it was wrong at this early stage of the litigation to dismiss Plaintiff’s case and deprive them of their day in court. Plaintiffs look forward to the vindication of their claims on appeal.”

ABIM may have thought they won this case on dismissal, but it looks the plaintiffs' claims will get a second more critical review of the case with the 3rd Circuit Court of Appeals.

-Wes

Physicians wishing to support the plaintiffs in this unprecedented action are encouraged to contribute here.

Why the U.S. Specialty Boards Were Sued and Why Those Lawsuits Are Important

I hope every working U.S. physician takes 9 minutes to view this video on why the lawsuits against  the American Board of Medical Specialties (ABMS) member boards were filed and why those lawsuits are so important to our profession.

Please view and share with your colleagues.

An update on the status of those lawsuits will appear on this blog's pages soon.



-Wes

What Do Working Cardiologists Really Think About the ACC's CMP Pathway?

What do US cardiologists and electrophysiologists REALLY think about the American College of Cardiology's (ACC) heavily-promoted collaboration with the American Board of Internal Medicine (ABIM) to create their "Continuous Maintenance Pathway" (CMP) for continually maintaining their ABIM board certification?

That's a question I wanted to know, so I helped create a quick 5-minute survey on the matter open to US cardiac electrophysiologists, cardiologists, and heart failure specialists.

I hope to have the results compiled by the Heart Rhythm Society in May, 2019.

I look forward to your responses and thoughts. Additional comments regarding the CMP program not covered in the survey can be left in the comments on this blog post.

Thanks-

-Wes

The ABMS Spider and the Fly

Mary Howitt

“Will you you walk into my parlour, said a Spider to a Fly;
'Tis the prettiest little parlour that ever you did spy.
The way into my parlour is up a winding stair,
And I have many pretty things to shew when you get there.
Oh, no, no! said the little Fly; to ask me is in vain:
For who goes up that winding stair shall ne'er come down again.

Said the cunning Spider to the Fly, Dear friend, what can I do
To prove the warm affection I have ever felt tor you?
I have within my parlour great store of all that's nice:
I'm sure you're very welcome; will you please to take a slice!
Oh, no, no! said the little Fly; kind sir, that cannot be;
For I know what's in your pantry, and I do not wish to see.

Sweet creature, said the Spider, you're witty and you're wise;
How handsome are your gaudy wings, how brilliant are your eyes!
I have a little looking-glass upon my parlour-shelf;
If you'll step in one moment, dear, you shall behold yourself.
Oh, thank you, gentle sir, she said, for what you're pleased to say;
And wishing you good morning now, I'll call another day.

The Spider turn'd him round again, and went into his den,
For well he knew that silly Fly would soon come back again.
And then he wore a tiny web, in a little corner sly,
And set his table ready for to dine upon the Fly;
And went out to his door again, and merrily did sing,
Come hither, pretty little Fly, with the gold and silver wing.

Alas, alas! how very soon this silly little Fly,
Hearing his wily flattering words, came slowly fluttering by.
With humming wings she hung aloft, then nearer and nearer drew.
Thinking only of her crested head and gold and purple hue:
Thinking only of her brilliant wings, poor silly thing! at last,
Up jump'd the cruel Spider, and firmly held her fast!

He dragg'd her up his winding stair, into his dismal den,
Within his little parlour; but she ne'er came down again.
And now, my pretty maidens, who may this story hear,
To silly, idle, flattering words, I pray you ne'er give ear;
Unto an evil counsellor close heart, and ear, and eye,
And learn a lesson from this tale of the Spider and the Fly.

~By Mary Howitt, 1829
* * *

If you do Maintenance of Certification, you are just a silly little Fly.

It is chillingly apposite: for the American Board of Medical Specialties (ABMS) and their 24 member boards' to live, autonomous independent-thinking physicians must die.

Spiders can never stop being Spiders.

"And now, my pretty MOC maidens, who may this story hear,
To silly, idle, flattering words, I pray you ne'er give ear;
Unto an evil ABMS counsellor close heart, and ear, and eye,
And learn a lesson from this tale of the Spider and the Fly..."

... then donate to Practicing Physicians of America's expanded legal fund drive.

-Wes

Ending MOC Nationwide

Continuing education for physicians is important (and we've been doing it all our lives on our own), but when working physicians' right to care for their patients is threatened by unaccountable non-profit testing organizations that have serious undisclosed conflicts of interest, we will take action.

 -Wes



P.S.: Patients, doctors: want to help? You can still donate.

On Trust

Elizabeth A. McGlynn, PhD, immediate past chair of the ABIM Foundation and Vice President for Kaiser Permanente Research and Executive Director of the Kaiser Permanente Center for Effectiveness and Safety Research (CESR) with Richard Baron, MD, President and CEO of the American Board of Internal Medicine,  at the 2018 ABIM Foundation Forum on "(Re-)Building Trust"

Recently, the ABIM Foundation hosted a webinar entitled "(Re-)Building Trust." Oh, the irony. The fact they need to have such a conference is telling of the dire straights the staid and outdated medical credentialing complex has become.

As physicians who funded the ABIM Foundation, why do we fund such nonsense?  The American Board of Internal Medicine has never sufficiently explained why this organization felt compelled to use over $78 million of physician testing fees to create the ABIM Foundation or how and why it uses that money. Is it really to fund such conferences?  Or might conferences like this really be a distraction for the real reason the ABIM Foundation was created: their retirement fund. By the way, whatever happened to those funds shipped off to the Cayman Islands? Why will we lose our privileges at hospitals or insurance payments if we don't pay into this scheme? And why is the ABIM Foundation colluding with Kaiser Permanente directors? What does Kaiser get for this relationship?

If physicians trusted the ABIM, we would not have to ask such questions and the ABIM Foundation would not have to hold conferences on "re-building" trust.

Three years ago, Richard Baron, MD issued the now infamous: "We got it wrong" mea culpa press release when the 2014 iterations of Maintenance of Certification (MOC) foisted on US physicians resulted in a powerful working physician backlash. Lots of soft-shoe, "listening," and MOC program changes have occurred since then. But in reality four years later, little has changed other than parsing our payments into annual aliquots rather than a single lump sum every-10-year payment. The growth of fees is back on schedule, climbing an incredible 276% in the past 18 years.  Even the ridiculous Part IV of MOC is back as before.

It is hard to trust any business, especially a nonprofit organization when they ignore the customer.

We should not lose sight that physicians are the customer of ABIM, not patients. We pay for their medical accolade and the paper certificate that ABIM issues when we successfully complete our initial Board certification and (now) subsequent MOC requirements.

There are many within the US medical board credentialing system who feel otherwise; for them, they are there to serve "the public." Yet this deflection is little more than a propaganda message created to justify their use of our money for their political and financial purposes.

When we see our funds continuing to be wasted at Las Vegas convention venues for American Board of Medical Specialties meetings with their "stakeholders" we realize that this old-school attitude of colleague disrespect and self-importance is endemic to the entire US medical board certification and medical credentialing industry. Hard to re-establish trust with overt demonstrations such as these.

-Wes

PS: Wonder what you can do to change things?  Donate here and get a free book at the same time! We're 78% of the way there!

Enough is Enough

It is 8:30PM CST on the 23rd of May, 2018.

The American Board of Internal Medicine (ABIM) has still not posted their financials from fiscal year 2017, due May 15th, 2018 after an extension is granted by the Internal Revenue Service, on their website. I wouldn't be surprised if they're insolvent, or close to it.

Maintenance of certification (MOC™) is expensive, costing physicians over $23,000 every 10 years in fees, travel, and time from work. Doctors are sick and tired of being manipulated and coerced into playing the continuous certification game created by the non-profit ABIM that has never been independently proven to improve patient safety, care quality, or patient outcomes after a doctor's initial board certification. Doctors are especially sick and tired of these unaccountable member boards of the American Board of Medical Specialties (ABMS) mandating busy work that, if not performed, would limit our ability to maintain our hospital credentials, receive insurance payments, or even obtain state licensure.

We are also sick and tired of being ethnographic research subjects and "HIPAA Business Associates" for the member boards of the ABMS so our data can be bought and sold while board members and officers of the ABMS member boards enjoy their multi-million dollar condominiums with chauffeur-driven BMW town cars, office buildings, first class and spousal air travel, Cayman Island retirement funds, and health club memberships all on our hard-earned nickel.

The conflicts of interest created by MOC spread far and wide: BCBS, CECity/Premier, PearsonVue, ABMS Solutions, LLC, IPC The Hospitalist Group, National Committee on Quality Assurance, American College of Physicians, Wolters Kluwer, Reed Elsevier, UCSF, Massachusetts Medical Society, the AMA, AHA, CMSS, among others.

The financial orgy within the bureaucratic halls of the ACGME has been going on for years at the expense of hard-working doctors. MOC fees alone have mushroomed 244% from 2000-2014 to fund these shenanigans. Numerous doctors are burning out, or quitting altogether, to avoid the ruse. It must come to an end. The integrity of our profession demands nothing less.

Please join me in this GoFundMe crowdfunding drive by Practicing Physicians of America to end MOC™ nationwide for all subspecialties. The specifics of the campaign's purpose are outlined in the campaign's "story" on the GoFundMe page. Please give generously.

It's time to stand up for what's right.

Enough is enough.

-Wes

Earning MOC™ Points: A Self-Paid Advertorial

As a follow-up of my earlier post on the American Board of Medical Specialties' (ABMS) Maintenance of Certification™(MOC™) program's tax on medical education, I was sent the "approved" responses of two different physicians that were required to answer questions to "earn" ABMS MOC™credits from the Heart Rhythm Society (HRS) Scientific Sessions after the meeting. These responses were "approved" by an HRS "reviewer" so the doctors could apply these points to remain "Board certified" and employed with their hospital systems. Each doctor had to write between 50 and 100 words (no more, no less) in response to questions posed by the ABIM. Despite their different responses, each received the exact same "feedback" that included links to various Heart Rhythm Society, American College of Cardiology, AMA, ABMS and non-governmental organizations' policies and web pages.

(See Physician 1's responses here and Physician 2's responses here.)

Given these canned responses to these physicians feedback, how is this time-consuming, costly, and meaningless "feedback" exercise for "earning" MOC™ points anything but a self-paid advertorial for the HRS, ACC, AMA, ABMS, and other non-governmental organizations?

It is a sad commentary that our own subspecialty societies legitimize this corrupt process despite all that we know about it today.

-Wes

An Internet Quiz: ABIM's Website Moves the Goalposts Again

The Internet loves mystery...

and cover-up.

There are very bright minds out there, and nothing gets those juices flowing for the dedicated Internet sleuths than when someone is trying to hide a carefully crafted change that benefits the Big Guy and screws the Little Man.

Lately, I've been watching the myriad of changes to the ABIM website.

It's got a whole new look and feel, full of big flashy graphics, but little on content. They will argue, no doubt, that it's all made to improve the navigation on their website and to introduce the bold new ideas they have concocted to be sure the fine print is missed.

So here's the challenge.

Take a minute and go the the ABIM website. (Warning, you'll need more than just a minute for this contest, but if you've got the time, this might satisfy criteria for some MOC points/CME credit).

Click on the Maintenance of Certification banner.

Look over to the left and find the "Policies" button. Here's what the screen looks like today:

(Click to enlarge)

Scroll down to look at what you've missed below the fold, as shown here: 

(Click to enlarge)

Now, this is where things get fun. It will be like The Price Is Right, where Bob Barker asks the contestant to look behind Door Number 1, Door Number 2, or Door Number 3. Go ahead, and click on one of those drop-down arrows of your choosing. What you don't realize, it that behind every one of those arrows, is the hidden surprise that has changed - your MOC® contract with ABIM in all its (hidden) glory.

So here's the challenge...

... which part(s) has(have) changed in the last six months?

Good luck!

-Wes

ABIM Stationary Sidebars: MOC and UCSF

I attended the University of California, San Francisco's (UCSF) electrophysiology program from 1993-1994. As I continue to explore the myriad of conflicts of interest inherent to the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program, it has come as quite a surprise to me that so many members of my alma mater (and the institution itself) were either passive or active participants in  the strongman tactics used by the American Board of Internal Medicine (ABIM) as a "message and deterrent" (as explained by former President and CEO of the ABIM, Christine Cassel, MD) to control the ABIM/ABMS monopoly on continuing medical education in the United States.

Let me explain.

In a retaliatory letter dated May 8, 2012, authored by Ms. Lynn Landon, the non-physician Chief Operating Officer of the ABIM at the time, Jaime Salas-Rushford, MD was accused of forwarding, prior to ever taking the ABIM Board certification exam, board review questions to the ABIM-certified instructor of the CME-accredited Arora Board Review course. About three years after the fact and after 139 others had already been sued or sanctioned for attending the same course (or at the very least, like a flashback to the McCarthy era, had warning letters "added to their file") this retaliatory letter declared that ABIM imposed an immediate, unlimited revocation of Board certification of Dr. Sala-Rushford and to "notify the Medical Board in every jurisdiction in which you are licensed" without due process.

On the stationary sidebar of that letter appear the names of the officers of the ABIM and it’s board members at the time: Chair Catherine R Lucey, MD, Chair-Elect Robert M Wachter, MD, Secretary-Treasurer Talmadge E King, MD, and President and CEO Christine Cassel, MD among others. Were these leaders listed in the sidebar mere figureheads of the ABIM when this occurred or were they ultimately responsible for the organizations' actions as their positions suggest?

It is remarkable that three of the above senior ABIM leaders were on staff at UCSF at the time. These same individuals now hold significant leadership positions at the USCF medical school. Dr. King serves as Dean of the UCSF Medical School since 26 May 2015, Dr. Lucey as the Vice Dean for Education, and Dr. Wachter serves as Professor and Chair of the Department of Medicine. In addition to their current academic positions at UCSF, these same individuals hold leadership in other organizations within the Accreditation Council for Graduate Medical Education (ACGME):

• Dr. Lucey serves as an at-large board member of the American Board of Medical Specialties 2016-2017 and on the Board of Directors of the of the Association of American Medical Colleges (AAMC).


• Dr. King has a long history of serving on the Board of Directors of the National Committee for Quality Assurance (NCQA) from 2010-2017 as an unpaid board member and currently works alongside the organization’s founder and President, Ms. Margaret E. O’Kane. Remember that NCQA, under Ms. O'Kane's direction, developed, maintained, and expanded the Healthcare Effectiveness Data and Information Set (HEDIS), the nation's most widely used quality measurement tool and has grown to a $50 million company with almost 300 employees. NCQA is also the main accreditor of recognized medical homes and one of two accrediting organizations permitted by federal law to accredit plans in the new health insurance exchange marketplaces that came online October 1, 2010, under the Affordable Care Act (ACA). Because the NCQA also credentials insurance providers as part of the ACA, one insurer quality metric they created requires physicians to "maintain" their certification via ABMS MOC programs if they want to receive payments from those insurers. Furthermore, the NCQA and the ABMS will continue to directly benefit from "quality" rules that they have put into place and lobbied Congress to enact laws such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA's Merit-based Incentive Performance is MOC on steroids (see comments to the final rule). While NCQA maintains the quality measurement tool that is used in MACRA to determine US physician pay based on their notion of care "value," much of the NCQA's own IRS 2015 Form 990 is redacted. Who is protecting our patients' interests when even the IRS allows this to occur?


• Dr. Wachter has his own financial conflicts with MOC that also benefitted the UCSF. According to IRS Form 990's, in 2012 when the above sanction letter was issued, Dr. Wachter served as 'Director-Chair" of the ABIM earning $38,888 from the ABIM and $6,626 from the ABIM Foundation.
  
  While serving as "Director-Chair" of the ABIM and Director of the ABIM Foundation, Dr. Wachter was also simultaneously serving as Director of the IPC The Hospitalist Company, Inc, reportedly running a “leadership development course (at UCSF) for their practice group leaders.” Dr. Wachter's financial haul from his relationship with IPC was significant. He pocketed 1,355 shares of IPC stock valued at $50.68 on 1 Aug 2013 and another 2650 shares of stock valued at $58.50 on 2 January 2014. According to SEC filings, he earned $210,586 in 2014 ($ 108,000 as cash, $ 55,000 in stock and $ 47,526 in options). USCF benefitted from a fellowship grant with IPC brokered by Dr. Wachter that began sometime in 2010 or 2011 (Dr. Wachter's description of the program was published on his blog 18 November 2011.) On 17 June 2014, the Department of Justice filed suit against IPC Hospitalist Company alleging the company overbilled federal health insurance systems for physician evaluation and services. Nonetheless, it appears Dr. Wachter still received a stock option award of 2186 shares of IPC on 2 Jan 2015. Undeterred by the DOJ suit (or perhaps because of it), TeamHealth acquired IPC Hospitalist Company for hefty $80.25 per share on 23 Nov 2015, again profiting Dr. Wachter and UCSF (with whom he had a publicly-disclosed sharing agreement where he kept 80% and UCSF received 20% of this relationship). As of 17 Jan 2017, it appears a settlement agreement in the DOJ's suit against IPC The Hospitalist Company will be reached soon. In retrospect, watching Dr. Wachter doing an Elvis impersonation at Mandalay Casino in Las Vegas on behalf of corporate medicine at patients' expense with the tacit approval of the Dean of the UCSF Medical School reflects poorly on the University. These activities also serve to erode any remaining trust practicing physicians have on the unproven ABMS MOC program to serve in our patients' best interest.

It is remarkably coincidental that on 27 December 2012, an article appeared in the New England Journal of Medicine by one of Wachter’s colleagues at UCSF, Robert B. Baron, MD written in conjunction with John Iglehart, a “national correspondent” for the New England Journal of Medicine, explaining the controversy surrounding MOC and reinforcing the need for it. Dr. Robert Baron (no relation to Richard Baron, MD of the ABIM) never disclosed his simultaneous collegial associations with so many in leadership positions of the ABIM at the time, nor did either author mention the fact that the "NEJM Group" would be announced in March, 2013 to profit the Massachusetts Medical Society that included the launch of their Knowledge+ Maintenance of Certification “state-of-the-art adaptive learning” educational product April 16, 2014.

Who wouldn't want to join such a financial and reputational party bestowed upon these former ABIM leadership physicians? What medical center wouldn't like to benefit from the ABMS MOC system so many from UCSF have? How many other institutions are? Given what we now know about these colluding private organizations and their ethical and financial tactics, why haven't these respected leaders come forward to denounce the activities of the ABIM for which they served? Perhaps these leaders are fearful UCSF would lose their ACGME accreditation as a teaching institution eligible for additional Medicare training funds if they did. Or perhaps these individuals saw little risk of collateral damage to their professional reputation if ABIM used its strongman tactics against a small number of vulnerable, less prominent physician colleagues.

The irony of the ABIM requiring doctor clients of Arora Board Review subject to the sting operation organized by an undisclosed convicted felon to participate in “ethics” courses and pay additional fees to the ABIM before their board certification credential could be reinstated should be lost on no one.

According to USCF's own Faculty Code of Conduct: "The integrity of the faculty-student relationship is the foundation of the University’s educational mission. This relationship vests considerable trust in the faculty member, who, in turn, bears authority and accountability as mentor, educator, and evaluator. The unequal institutional power inherent in this relationship heightens the vulnerability of the student and the potential for coercion. The pedagogical relationship between faculty member and student must be protected from influences or activities that can interfere with learning consistent with the goals and ideals of the University." I would argue that the unequal institutional power carried by the ABIM (and other ABMS member boards) that can revoke a physician's ability to practice or earn a living on the basis of an unproven repeated testing is even larger and warrants even greater scrutiny.

It is clear that the complex financial interrelations of many tax-exempt private organizations that require the ABMS MOC credential have developed over the years to monopolize the physician continuing education process. In my opinion, it is far too coincidental that all of these physicians a single institution just happened to hold unelected leadership positions in so many of these interrelated private entities that financially benefit from MOC at the same time. I also believe the fact that another physician from the same institution published a manuscript in the New England Journal of Medicine while his colleagues stood to benefit politically and financially from their positions gives the appearance of collusion. I believe the UC Board of Regents, Attorney General of California, and/or even the Governor of California have a responsibility to investigate the use of public monies and academic positions to benefit these many non-governmental private entities that act outside of University responsibilities and act, as one independent journalist described them, "more akin to a protection racquet."

The ABMS Maintenance of Certification controversy and those culpable for its strongman tactics extends far further than just the ABIM. When respected leaders of the academic community fail to speak out about the irresponsible activities that occurred during their tenure with the organization, I believe they passively condone them. I suspect this is why we have heard little from other members of the academic community since the collusion extends to current board members of the NCQA, AAMC, ABMS, the New England Journal of Medicine, and other prominent academic institutions like UCSF.

Practicing US physicians voted to end the ABMS MOC program before the AMA House of Delegates meeting in June 2016 because of the unexplained financial dealings and the strongman tactics employed by the organization, yet it continues, even now. This no longer surprises us since the AMA is a member organization of the ACGME, too.

How high do the conflicts go in the US medical education system?

It is now clear they go all the way to the top. It is also clear why.

It's time for the AMA to shut the ABMS MOC program down as practicing US physicians have voted because it's doing more harm than good, not only to reputable practicing US physicians nationwide, but to their patients and academic institutions (like my alma mater) that purport to train and educate physicians to become ethical, hard-working, trustworthy doctors without fear of reprisal for educating themselves any way they choose.

-Wes

Disclaimer: I serve as an expert witness on behalf of Jaime Salas-Rushford, MD.

ABIM Needs to Prove MOC Useful

From Medical Economics:

(Click to enlarge)

- Wes

P.S.: Here's my rebuttal to the same article that Medical Economics refused to print.

Hillary Clinton's Physician Does Not Participate in MOC

In case anyone cares, Lisa R, Bardack, MD, reportedly Hillary Clinton's personal physician who issued a letter in 2015 concerning Ms. Clinton's fitness to run for President of the United States, does not participate in the American Board of Medical Specialties' Maintenance of Certification (MOC) program:

(Click to enlarge)

Classic.

-Wes

Too Little Too Late: The ABIM Foundation Sells Its Condo

It was a story that broke on this blog nearly two years ago when the American Board of Internal Medicine (ABIM) Foundation was putting their luxury condominium, complete with a chauffeur-driven Mercedes S-Class town car that was purchased with physician certification and re-certification fees, up for sale.

Over 550 days later, we find the notorious ABIM Foundation condominium was finally sold on 6/21/2016 for $1,650,000 representing an up-front cash loss of $650,000.

But let's not forget the other associated fees required to sell a condo:

Real estate commission (6%): ($99,000)
Transfer Tax as buyer (2%) (2007): $46,000
Transfer Tax as seller (2%) (2016): $33,000
Title insurance: $10,000
Other fees: deed preparation, attorney fees, recording fees, etc. $10,000.
Furniture expense: $56,267


And then there's the annual condo fees, cable, phone, electric, cleaning, etc., that came to $41,000-$50,000 annually (approximately $450,000 over 9 years) (Source: Richard Baron, MD, President and CEO of the ABIM and ABIM Foundation)

All told, ABIM took $2,356,267 million of ABIM diplomat's cash and lost at least $1,265,267 on our behalf.

So much for "Choosing Wisely®."

But let's face it, incurring a financial loss on an "investment" is not necessarily illegal. After all, any of us could have made a horrible investment decision.  Rest assured we'll soon hear the ABIM trying to justify their real estate loss because they would have lost this money anyway if they had to pay hotel costs for all of their out-of-town guests and programmers from India eager for a cheap place to stay.

But we should ask ourselves now with the sale of this condominium, what was illegal at the ABIM Foundation? Anything?

Tax Fraud

First, recall that Dr. Baron claimed in my communications with him that much of the condominium expenses they claimed on their tax forms as program service expenses was actually a depreciation expense they lumped into the "program services expenses" of the condominium. Yet the ABIM and their accountants never claimed depreciation under the separate line item on their federal IRS Form 990 for this expense.

Honest mistake?

Unlikely. After all, other tax filing discrepancies with the ABIM Foundation have occurred repeatedly and systematically over many years. Any credible accounting audit should have disclosed most of them.

For instance, surely someone at the ABIM knew the difference between the two states of Iowa and Pennsylvania, didn't they? So why was the ABIM Foundation domicile claimed as Iowa for years when, in fact, it was domiciled in Pennsylvania but never disclosed? And isn't it striking that the ABIM Foundation was claimed for years as being formed in 1999 until this blog disclosed that it was actually created in 1989, some ten years earlier? Only in its most recent tax filings has that little "oversight" miraculously been corrected without explanation to the Internal Revenue Service.

And why didn't the ABIM disclose that it was lobbying Congress on its tax forms when it had been doing so for years? Was this merely a mistake? Or was it because the ABIM and their Foundation would have opened themselves up to closer scrutiny and lost their tax-exempt status if they had?

Unethical Research Practices

Finally, we have to ask ourselves just what kind of research on physicians for the betterment of health care requires a $2.3 million condominium? After all, the ABIM Foundation has always heavily touted their research work and publications.

Some may argue there wasn't "research" being conducted at the ABIM Foundation but rather "quality assurance" or "Quality Improvement" exercises performed there. If so, then why did the ABIM Foundation promote it's pioneering research by using the term at least five times on a single web page in May of 2007?

Archived Screen May 2007 - ABIM Foundation
(Click image to enlarge)

We also find that the ABIM funded "various research projects" at its Foundation in the fiscal year 2008 with the transfer of $6,000,000 of ABIM diplomat fees:

Evidence of ABIM Funding "research projects" at the ABIM Foundation
for $6 million in Fiscal Year 2008
(Click image to enlarge)

There is no escaping the fact that this was a very serious effort at conducting "research" on physicians.

Or not.

Was the whole "research" story told by the ABIM and ABIM Foundation just a front for other activities? I wish to bring my reader's attention that the ABIM Foundation no longer has the word "research" appear anywhere on its website. Instead, there are only words like "Medical Professionalism Charter," "Initiatives," "Grants" and "Choosing Wisely®." The cover-up continues.

Credentialing of physicians involves human testing. As such, it appears the ABIM Foundation unilaterally decided to perform research on physicians without informed consent, without an impartial Investigational Review Board, and without a clear research hypothesis, method, or analysis of the harms they might cause.

"Research" conducted in such a manner is dangerous for many reasons and some of the most egregious examples of dangerous research have happened in government agencies or when the individual or collective social beliefs or dogma were imposed on others as justification for "research."

The Nuremberg Doctrine which rose from the World War II war crimes is very clear in its requirements for human subject research, especially as it pertains to proper consent. From my recently conducted bi-annual CITI Training:

"The voluntary consent of the human subject is absolutely essential.

This means that the person involved should have the legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements the subject matter involved, as to enable him to make an understanding and enlightened decision. This latter element requires that, before the acceptance of an affirmative decision by the experimental subject, there should be made known to him the nature, duration, and purpose of the experiment; the method and means it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person, which may possibly come from his participation in the experiment.

The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs, or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity."

It goes without saying that human subject research that involves real estate investment strategies to fund research on practicing physicians is unethical (at least) and likely highly illegal. As we have seen, the MOC recertification program can cause significant harm to physicians, their patients, and their families, especially when this credential is tied to physician employment and remuneration. Worse still, the average failure rate of the unproven "Maintenance of Certification" re-certification metric has averaged 13.2% over the past 10 years with wide year-to-year volatility in pass rates using an inconsistent metric. Was the impact of funneling money from the ABIM to the ABIM Foundation for the ABIM Foundation's "research" really that harmful?

Absolutely.

But this story isn't about a condominium or its sale, is it? It's about the wholesale sell-out by some in Organized Medicine that have systematically and repeatedly turned their back on their fellow practicing physicians and the doctor-patient relationship for their own political and financial benefit. For this story is not just restricted to the ABIM or its Foundation. This story extends to all member organizations of the Accreditation Council for Graduate Medical Education (ACGME) that tie the ABMS Board certification credential to medical training program directors, lab certifications, and a host of other regulatory traps, too. So it should come as a surprise to no one that we find more recently that each of these organizations appears to have been complicit with the ABIM Foundation moving funds derived from practicing physicians' "research" fees offshore.

In the end, the entire American Board of Medical Specialties' Maintenance of Certification® story has alway been about making money for their coffers at the expense of practicing physicians, irrespective of the specialty.

Always has been and always will be.

It's NEVER been about "Choosing Wisely®."

-Wes

Pennsylvania Medical Society Spearheads Effort to End MOC Nationwide

Recently, the Pennsylvania Medical Society sent this letter to the executive vice presidents of all US state medical societies and many specialty societies regarding their vote of no confidence regarding the ABMS Maintenance of Certification® (MOC®) program and the current leadership at ABIM, stating specifically:

"... We believe that their current leadership is not capable of reforming the process in a timely, academically meaningful, and fiscally responsible way.

In keeping with the consensus of our members and physicians across the country, we call for the immediate replacement of the entire ABIM Board of Directors and leadership with new leadership, representative of physicians actively participating in the full-time practice of clinical medicine. The undersigned organizations would further offer to assist the ABIM and any of the ABIM subspecialties with the formation and transition to a new Board that is representative of and accountable to the physicians whom they will certify. ..."

For those interested in learning more or who's state is ready to sign on can email Dr. Scott Shapiro, President of the PA Medical Society at stat@pamedsoc.org‎ for more information.

Please forward a copy of this letter to all of your practicing physician colleagues (irrespective of specialty) and ask each of them to contact the leadership of their respective state medical societies and specialty societies to urge them to co-sign this letter and work with the PA Medical Society to end the corrupt ABMS MOC® re-certification requirement.

Only through aggressive, meaningful, nationwide collective action against this needless, unaccountable, expensive, and coercive ABMS re-certification program will practicing physicians restore sanity to our own life-long continuing medical education process.

Thank you-

-Wes

A copy of the letter to circulate to your colleagues can be downloaded here.

AMA House of Delegates MOC Session Recap

It was a beautiful day in Chicago yesterday: sunny, not too humid. I left home early. The sun had risen some time ago and could be seen reflecting off the lake to the front of the downtown skyscrapers highlighting every detail of their construction. Lake Shore Drive is magnificent this time of day. I parked, as many must do each day, down in the basement of a nearby parking garage, making the "early bird special" parking fee of $16 when your arrive before 8 AM.

Nice.

(Click to enlarge)

I entered the Hyatt and saw a large meeting room across the foyer with a "Southeastern Delegate Meeting" sign outside the huge room. Lots of people with the representative state name on a card in front of them and a man in a bright kelly green jacket sitting next to the speaker stand who looked like a preppy leprechaun: the "Vice Chair." Heh.

I had to find registration at the Hyatt Regency Chicago: no easy task for someone who's never attended the AMA House of Delegates meeting, but approached what must have been a senior delegate adorned with his AMA badge with multi-colored tags draped some 14" beneath it highlighted by political stickers and little metal badges (I learned later you got some of these after contributing to various political action committees). He was cordial and helped direct me to the subterranean registration desk in the East Tower.

There were delightful ladies more than willing to help. "Are you a delegate?" they asked. "No, just a speaker." They gave me a registration card and I filled it out and was promptly handed a badge of my own with a lonely gray "speaker" badge dangling below.

"Don't listen to a thing he says, he's a doctor," someone said behind me. I turned around to find Charles Kroll, who has also just arrived, waiting to register.  I hadn't seen him for two years since we started to work together on the ABIM story. He grabbed his badge and we headed upstairs. I called David Winchester, MD, a delightful young cardiologist that I was introduced to via Twitter  (cardiologist and Florida delegate) and he joined me and Mr. Kroll for coffee.

AMA House of Delegates MOC Meeting
(Click to enlarge)

Next, I called Charles Cutler, MD from the Pennsylvania Medical Society who met us in the lobby of the East Tower. We headed to the meeting room and he introduced me to numerous people: Steven E. Weinberger, MD of the American College of Physicians (Executive VP and Chief Executive of the ACP), Stephen R. Permut, MD, JD, (Chair of the Board of Trustees of the AMA), and newly-elected Board Member of the American Board of Internal Medicine (ABIM), Yul Enjes, MD, among others. Only later did I realize Lois Margaret Nora, MD, President, and Chairman of the American Board of Medical Specialties (ABMS) was there, too, among many others (seated in the back, far right). Many stood in the back of the room despite available chairs in the front of the room (some things never change).

As luck would have it just before we began, the projector bulb blew shortly after it was turned on so another projector had to be retrieved. Meanwhile, the videographer had set up and was ready to go, but we had to remain seated as we spoke to use the available microphones. Once the new projector was secured, we were ready to begin.

Mr. Kroll went first (slides at link, video here) and explained his background as a forensic accountant specializing in health care and non-profits to the audience. He began discussing his educational background, credentials, prior experience with other non-profit shenannigans in Minnesota (Alina/Medica scandal) and his experience working with the attorney general there. He then explained how he stumbled across the ABIM story (a former article by Linda Girgis, MD asking if ABIM was "extorting" physicians). He pulled the ABIM's financials and immediately found discrepancies and outlined many of his findings to the audience. You could see heads shaking with disbelief. He kept it simple and understandable.  It was devastating. He then told the story how he contacted a mainstream media outlet who requested the last twelve years of audited financials from the ABIM and how the ABIM refused to produce all but the last year, and only if they met in persons to review them together. Evidently, the reporter politely declined and then requested these financials from the PA Attorney's Office (who never responded).  Only after a request was made to the press secretary of the PA Governor's office were the last two years' of audited financials produced. Mr. Kroll, who had these full financials in his possession, then noted that when the ABIM published them, they failed to publish six key parts of those financials on its website. Only after he disclosed this fact in an article in MedCityNews, did the ABIM recant and post the full financials. Finally, we concluded with a description of the meeting he help with the Iowa Attorney General's office and the recommendations he made regarding actions the Iowa AG could impose on the ABIM and their Foundation.

I was next.

In my presentation (a rather large Powerpoint presentation can be downloaded here, video here), I discussed my background, the background of how Board certification, how the philosophy of lifetime certification morphed to time-limited based on the ABIM's assertion that older physicians lost their skills over time, but then pointed to the paradox of the "grandfathering" of physicians and the inherent age discrimination against our most vulnerable physicians with that policy change. I also explained patient's definition of the excellent physician vs the ABIM's definition, and reviewed the costs in terms of out-of pocket costs and time involved (detracting from patient care). I also touched on the creation of the ABIM Foundation and the transfer of funds from the ABIM to the Foundation for "research" and showed the webpage asking for physician data for more "research" without informed consent and disclosure to physicians who were serving as study subjects in violation of the Belmont Report. With the purchase of the ABIM condominium, perhaps they were performing investment research instead, I suggested. I then summarized much of what has transpired with the ABIM and asked the important question, "How did it get this way?" and why I thought it happened. Finally, I summarized the disturbing code of silence that has surrounded the ABIM controversy by using the "Little Red Hen" allegory. The only people who will fix this mess is practicing physicians, starting with a full investigation of the responsible parties.

Next up was Bonnie Weiner, MD, board member of the National Board of Physicians and Surgeons (NBPAS.org) who gave an update of their efforts to create a more credible board credential for assuring continuing medical education. She expressed concern that future modifications to MOC will result in making one wasteful test taken once every ten years into many worthless tests over the same time period. She summarized the philosophy and finances of the NBPAS.org and explained that she could no longer serve as an interventional cardiology program director because she refused to perform MOC for that credential. (So much for "voluntary" certification!) She noted over 30 hospitals now accept NBPAS as an alternative to NBPAS.org and emphasized the need to have competition in the credentialing market.

With the last presentation by Scott Shapiro, MD, President of the Pennsylvania Medical Society, a shot was fired across the bow of the ABIM. Dr. Shapiro announced that the PA Medical Society was publicly announcing  their "vote of no confidence" against the ABIM and approved funds to evaluate legal options against the ABIM:

Today, at the AMA Annual Meeting in Chicago, our Pennsylvania Medical Society Delegation convened a national discussion panel to present their research findings, insights, and recommendations regarding the failures of the American Board of Internal Medicine and the MOC process. The discussion regarding the actions, finances and possible historical motivations for the ABIM actions was eye-opening and alarming.

Notably, during the conference, we announced that our PAMED Board of Trustees—after reviewing the available data and recent ABIM actions—voted and are now issuing a statement of no confidence in the ABIM's Board and leadership.

We also announced that, earlier this year, our PAMED Board approved the necessary funding to move forward with obtaining a legal opinion into whether PAMED would have standing to file a lawsuit against the ABIM. We hired a firm and recently received their opinion that not only would we have standing but they found potential legal claims consistent with our concerns that could be filed in a lawsuit against the ABIM.

Physician leaders from many other states have inquired about how their state can join PAMED's efforts. We look forward to these and other strategic conversations in the near future.

Boom.

You could have heard a pin drop.

After his announcements (and I probably missed a few key words), the floor was open for question and answer. Lots of people asked questions respectfully. Many were in support. Some were disappointed that there was not a more broad perspective of the opposite arguments for MOC on the panel. One physician with lots of tags on his chest approach the microphone saying," I learned a lot today in this session. Most of all I learned that I'm really glad I never became an internist." (He was an anesthesiologist). The room burst into laughter. He then went on to express his like of anesthesia's "MOCA minute" initiative but never disclosed if he had conflicts with the program or how much it cost. (By now, Dr. Nora from the ABMS had joined the question and answer line.)

It had to be difficult for Dr. Nora to enter this room, but I respected the fact that she came to the microphone to point out her views.  Unfortunately, rather than mentioning anything about the corruption we had just uncovered, Dr. Nora seemed upset that I had been inaccurate with my portrayal of where the ABMS gets their money (I am paraphrasing here). She also commented that we have been given a privilege to self-regulate and that we should consider carefully what we are doing. I then asked her a question as she walked away. She turned to answer. My question was this: "Have you ever studied what happens the physicians that you fail and what happens to their patients in turn?"  She stated she didn't "understand" my question and then proceeded to redirect to another topic before turning to walk away. Perhaps there will be an audio feed soon of this interaction. It wasn't one of our chief regulator's best moments.

Other questions kept coming, with many shifting to "what's next?"  Unfortunately the session went 30 minutes over and another meeting needed the room.

Finally, it was over.

I would like to take this moment to thank Charles Cutler, MD of the Pennsylvania Medical Society for his invitation to speak in this important venue. I am glad I could meet the players in this saga firsthand. There's no excuse for delaying any longer. Everyone knows the problems. Illegal stuff has occurred.

I can only hope those responsible take meaningful and serious steps to resolve the financial malfeasance, corruption, cronyism, and lack of accountability that has been ongoing at the ABIM (and other affiliated member boards of the ABMS hierarchy) for so long.  Otherwise, it's going to get very ugly very quickly.

Practicing physicians across the US have had enough of the ABMS MOC requirement shenanigans.

-Wes

AHA House of Delegates MOC Session Speakers, June 13, 2016
(L to R: Scott Shapiro, MD, Bonnie Weiner, MD, Charles Cutler, MD,
Wes Fisher, MD, and Mr. Charles P. Kroll)

P.S.: I will post a link to the videos of the sessions as soon as they become available. (Update: links added where appropriate above)